Knowledge Base Article

In 2009, CMS transitioned Part A inpatient medical review responsibility from Quality Improvement Organizations (QIOs) to Medicare Administrative Contractors (MACs) and Fiscal Intermediaries (FIs).

Along with this transition, CMS has made the reduction of combined Part A/Part B inappropriate claims payments through the Comprehensive Error Rate Testing (CERT) program a high priority for the Medicare program.  

So, what does this mean? For the first time one entity (MACs) have the ability to review Part A and Part B claims.

This past fall this ability became a reality for TrailBlazer (the MAC for Colorado, New Mexico, Oklahoma, Texas and the Indian Health Service), when they posted Notice ID 14572: "Part A/B Cross-Claim Medical Review: The Impact It Will Have on Physicians announcing that “to increase consistency in Medicare reimbursement, effective November 1, 2011, TrailBlazer will begin cross-claim review” of services. Two other notices were referenced in this announcement that Hospitals and Physicians should pay close attention to (Notice ID 14561: "Part A/B Cross-Claim Medical Review" and Notice ID 14362: "Joint Replacement Documentation").

Key Points from the TrailBlazer Notices:

• For the first time a MAC will be looking at the physician’s related outpatient claims when inpatients stay/service is denied.
• Physician documentation for inpatient services should be as robust and complete as their clinic/office (outpatient documentation).
• Hospitals may need to request and include physician clinic notes in their medical records to help support the medical necessity and other requirements of hospital procedures.

MACs are no longer simply looking at the medical necessity of the admission but also whether or not the procedure was medically necessary.